II HEALTH MANAGEMENT AND HEALm POLICY

Although health behavior research has consider­able potential value for the management or admin­istration of health services and for health policies, virtually no such research relevant to management has been conducted. The process of developing policy, moreover, has far too often neglected an appreciable body of health behavior research findings.

HEALTH MANAGEMENT

Some data exist on the differential use of managed care and fee-for-service by Medicaid patients and nonmedicaid patients. For example, Krieger, Connell, and LoGerfo (1992) reported that Medicaid patients made less use of managed care services than did non-Medicaid patients; that Medicaid patients used services in a different way than non-Medicaid patients, in particular, that they used prenatal services less frequently and in a less timely manner. While such studies present problems in rigor and control, they re­veal personal and social behavior factors that underlie care seeking, above and beyond the abil­ity to pay. They also reveal issues to be resolved by health service managers in the future in order to increase the productivity and profitability (and possibly even the effectiveness) of managed care. In Chapter 10, Daugherty presents an agenda for

health behavior research directly relevant to management of health services, and especially directed toward the increases in managed care that began in the mid-1980s and can be expected to continue through the eady 21st century.

HEALTH POLICY

Appropriate contexts for discussions of the relevance of health behavior research to health policy are considerations of what is meant by health policy, the behavioral factors that drive policy development, the role of government, and specific behaviors and risks toward which policy has been directed.

Health Policy: Toward a Definition

On the basis of extensive literature review of English language materials in medicine, nurs­ing, hospital administration, and the policy sci­ences, Rodgers (1989) reported that policy was seldom referred to as a generic concept, but was most often defined in terms of specific policy formulation: "Rarely was an actual definition of the term 'health policy' provided" (p. 697). Rodgers provides four attributes of policy as a concept: reflections of a particular attitude to­ward significant health issues that imply values

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182 PART II • HEALm MANAGEMENT AND HEALm POllCY

about some aspect of health care; expressions of a desire to move in a certain direction in relation to these values; involvement of some type of activity or behavior in relation to health care; and reference to a specific domain of health care, such as expenditures, organization of services, or health care personnel.

Often, terms such as "program," "legisla­tion," "regulation;' and "decision" are substituted for "policy," but policy need not be limited to legislation or regulations. It encompasses a wider array of values, decisions, and behaviors. Health policy, like all policy, needs to be considered as a product of human activity, preceded by a ques­tion or problem, and by the influence of various agencies, either persons or groups with specific interests or policy analysts or researchers (Rod­gers, 1989).

Behavioral Factors That Drive Policy Formulation

As a reflection of human activity, the devel­opment and implementation of health policy need to be examined in terms of personal, social, and political factors. Somers (1986) provides a discussion of changes in demography and in pub­lic sentiment that appear to affect the demand for care and ultimately the development of health policy. Her discussion includes health behavior data that show increasing public skepticism of new drugs and therapies, increasing emphasiS on patient autonomy and on laypersons assuming more responsibilities for their own health, and changing attitudes toward acute care conditions. The specific impact of these changes in health­related cognitions on demand for care and on health policy remains uncertain.

Kinston (1983), observing the British use of research on health services, suggests that the process of policy development is at risk for being co-opted by political factors and that what might appear to be a neutral "scientific" process is often a social construction. Kinston warns against the domination of the health services research pro­cess by a single, monolithic model, yet notes that

professional prestige, career openings, institu­tional reward systems, and social values all oper­ate to influence the production of knowledge and to move it in particular directions. Ulti­mately, these influences affect the formulation of health policy.

Particularly insidious examples of how eco­nomic and political factors affect health policy are provided in Nestle's (1994) account of how United States Department of Health and Human Services/Department of Agriculture Dietary Guidelines for Americans, the federal policy statement on diet and disease prevention, has been watered down, as a result of food lobbyist activities, to suit the economic interests of the food industry. Although basic nutritional guide­lines themselves had not changed, the substitu­tion of words such as "choose" for "avoid" lead to public misperceptions and increase the likelihood of inappropriate food purchasing and poorer nu­tritional behaviors.

In contrast, evidence of positive benefits of alcohol consumption, e.g., on coronary heart disease-remain excluded from policy formula­tions, and the position that drinking in modera­tion should be encouraged and taught to young­sters has been "expunged from the American scene" (peele, 1993, p. 80S). Peele claims the temperance movement in the United States-in reality, an abstinence movement - has a dispro­portionate influence on public attitudes toward, and thus policies related to, alcohol consump­tion. Comparisons of temperance with nontem­perance cultures suggest that alcohol policies reflect a society's reliance more on historical, cultural, and religious attitudes toward beverage alcohol than on supposedly scientific and medi­cal evidence (Levine, 1992, cited in Peele, 1993).

With violence increasingly being defined as a public health issue, appropriate measures should be taken to reduce it and the injuries it causes. Yet Kellermann (1994) identifies major gaps in statistics relevant to policy formulation, noting that guns are specifically excluded from the jurisdiction of the Consumer Product Safety Commission, that the domestic gun industry is

PART II • HEALm MANAGEMENT AND HEALm POllCY 183

exempt from regulations establishing design and performance, and that questions about firearms­related injuries were omitted from the National Health Interview Survey after 1972. Gun lobby interests have successfully prevented the estab­lishment of an appropriate database for intel­ligent policy development. Kellermann recognizes that these injuries and the societal ignorance about them are not accidental and urges collec­tion of relevant health behavior data to help ad­dress this issue.

Role of Government

The role of government and its agencies in regulating health behavior remains undefined. In the United States, federal or state policies or both regulate a range of health behaviors, including (but not limited to) the purchase and use of alcohol, tobacco, and firearms; driving and ve­hicular safety; food and drug consumption; as well as environmental factors related to pollu­tion; smoke and fire protection; and transporta­tion and occupational safety. States also regulate the training and performance of many health professionals.

Levy (1986) provides an insightful analysis of the linkage between governmental policy, the 1976 National Health Information and Health Pro­motion Act, and worksite health promotion pro­grams. She notes the dramatic increase of such programs and the relationship between several of them, those dealing with stress, smoking, fitness, nutrition, and hypertension, and the federal gov­ernment's health objectives.

At the mid-1990s, the role of government in underwriting, guaranteeing, or facilitating pay­ment for health services and in structuring or organizing or coordinating the delivery of health services and the activities of health professionals remains a focus of fierce political debate, as it has been for decades. A quarter of a century earlier, Kalimo (1971) demonstrated how health behav­ior data could be used to evaluate the impact of a government health insurance program in Fin­land. Such data showed that the introduction of

insurance had a positive impact in diminishing the effect of financial resources on care seeking and on reducing the ratio of care needed to care obtained.

High estimates or perceptions of costs-in contrast to actual costs-appear to be a barrier to seeking mammography among samples of United States women (Urban, Anderson, & Pea­cock, 1994); women who did not participate in screenings made higher estimates of their costs than women who did participate. Although pro­viding insurance reimbursement for mammo­grams might not itself improve the rate of partici­pation, if it influenced physicians' perceptions of patients' ability to pay, it might increase the like­lihood that phYSicians would recommend a mam­mogram, which itself is a major determinant of participation (Urban et aI., 1994). The question that logically emerges from such findings is: Does government have a role to play in providing such reimbursement?

At the same time, questions arise about who decides what is necessary care, who has what rights to experimental treatments, and whether there are there rights to care for non-necessary and nonestablished treatments (Mariner, 1994). Health behavior research has shown consider­able variation in individual perceptions of treat­ment effectiveness and appropriateness, and Mariner notes the lack of consensus in the medi­cal profession about what is standard, medically necessary treatment. This ambiguity raises the question of whether the physician, the insurer, the government, or the patient is to make the decision about appropriate and necessary treat­ment.

The absence in the United States of any pol­iCY, or coordination of policies, leads to major problems in maintaining appropriate levels of immunization for measles (e.g., Bernier, 1994), which should ordinarily be a simple thing. It also leads to confusion about who is responsible for what areas of public health. Pless (1994) relates this lack of a system to the underreporting of adolescent work injuries, with different govern­mental levels trying to place the burden of re-

184 PART n • HEAL11I MANAGEMENT AND HEAL11I POLICY

sponsibility on the injured youngsters and their families, assuming that simply providing them with information about what to do will result in their reporting such injuries. Accumulated health behavior research testifies to the inade­quacy and inappropriateness of such assump­tions. Pless raises the question of whether state health departments should be given the author­ity to ensure improved reporting in place of the assumption that injured persons will do so.

Questions arise continually about the limits of the governmental role, about how far health policy should go in relation to individual behav­ior. AIDS provides a case in which the public health interest is juxtaposed with human rights interests. Scheper-Hughes (1994) observes that in the United States, AIDS was viewed as a human rights crisis with some public health connota­tions rather than a public health crisis with some human rights connotations (as it was elsewhere, e.g., in Cuba), with the results that mandatory testing and mandatory notification of partners have never been implemented. Legitimate ques­tions arise about the effectiveness of such poli­cies and about whether mandatory notification of partners would be a barrier to persons seeking HIV testing. Potterat, Spencer, Woodhouse, and Muth (1989) provide a model for evaluating the benefits and costs of such notification and indi­cate that the nature of the condition nonetheless warrants notification, even in the absence of much data on the impact and acceptability of notification.

Wilder (1978), for example, examined the moral basis for an increased governmental role in lifestyle behavior and raised ethical questions about the limits to which health education pro­grams might go before they become coercive. In considering principles such as beneficence and paternalism, he cautions against overly simple moral justifications for intrusive, coercive gov­ernmental actions on behalf of health. Hayry, Hayry, and Karjalainen (1989) examined the Fin­nish policy toward smoking and, since it pro­tected others from harm, found major parts of it not paternalistic. Nor did they find most of it to

be that coercive or restrictive, only the banning of "strong" tobacco products, i.e., those with the high­est levels of tar, nicotine, and carbon monoxide. In Chapter 11, Nilstun provides a philosophical analysis of paternalism in relation to health policy and health behavior.

Specific Behaviors and Risks

The general question of how far policy should reach points to other more specific issues. Should governmental policy relate to the control of reproductive behavior, including regulation of the menstrual cycle? Such questions arise in the face of a technology, RU 486 (Misoprostal), that facilitates the interruption of pregnancy shortly after conception. "The desire to have access to a drug that inhibits or interrupts pregnancy is uni­versal" (Banwell & Paxman, 1992, p. 1400). Knowl­edge of human behavior in this area indicates that any policy that restricts access to such a drug will lead to a black market for that drug. Health behav­ior research suggests that definitions of preg­nancy and implantation will be problematic for any policy related to its use, as will the cultural definitions of when life begins. Moreover, the label it is given, Le., "contraceptive" or "aborti­facient" or "death pill," will have an impact on its availability (Banwell & Paxton, 1992).

Health policies generally tend to mandate individuals to change their behaviors rather than to mandate change in organizational, corporate, societal, political, or institutional structures. Even when institutions are subject to health pol­icy, they often fail to adhere to it. Berliner (1988) observes that hospitals engaged in patient dump­ing even though it clearly violated anti - patient dumping legislation and COBRA (Combined Om­nibus Budget Reconciliation Action of 1985). Ber­liner also suggested that even if economic dump­ing were eliminated, there would probably still be social dumping based on race, ethnicity, the nature of the insurance provider, and disease status.

In a view of several governmental goal state­ments for health and health promotion, including

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the United States Surgeon General's Healthy Peo­ple (1979), and Healthy People 2000 (1990), Lalonde's A New Perspective on the Health of Canadians (1974), the United Kingdom's Pre­vention & Health: Everybody's Business (1976), the American Public Health Association's Model Standards (1979), and the World Health Organi­zation's Global Strategy for Health for All by the Year 2000 (1977), McBeath (1991) makes clear the overemphasis in Healthy People 2000 on individual responsibility and comments that LaLonde's reference to "lifestyle" factors in health risks may have resulted in reinforcing and compounding the erroneous assumption that personal behavior is largely voluntary and a result of individual choice. There is a simultaneous fail­ure to recognize that lifestyle is influenced by life situations and that health status is a function of people's political, social, cultural, economic, and physical contexts. McBeath further observes the retreat of the United States government from support of the public health infrastructure neces­sary for attaining the objectives identified in its own documents, at the same time that other governments and agencies in Canada, Great Bri­tain, and Scandinavia are "repenting of exagge­rated stress on individual life-style, and embrac­ing an expanded concept of health promotion" (McBeath, 1991, p. 1564).

In relation to injuries reSUlting from vio­lence, traditional criminal justice policies based on deterrence, incapacitation, and rehabilitation target individual offenders and are ineffective. These policies should be broadened to include modification of high-risk situations and settings, and gun-control policy (Kellermann, 1994).

In addition to alcohol consumption, which the United States attempted to eliminate entirely through a constitutional amendment, with disas­trous results, major health policy efforts have been directed at injury control and tobacco use. Mortality rates show the impact of increasing the speed limits on United States interstate highways on injuries and presumably on the behaviors that lead to them (e.g., Baum, Lund, & Wells, 1989). Other data fail to show the anticipated impact of

high school driver education programs or de­layed licensure on fatal crash involvement, and in fact indicate that increasing enrollment in driver education simply increases the number of un­seasoned drivers on the road and thus increases the absolute number of crashes (e.g., Robertson & Zador, 1978).

In Chapter 12, Robertson examines policies directed at automotive injury control that mis­takenly focus almost solely on individual driving behaviors and desired injury control outcomes. Such policies fail to make appropriate use of available health behavior knowledge indicating that individual driving behavior is responsible for less of the variance in vehicular injuries than are poor automotive design and highway policies. In Chapter 13, Cummings Similarly shows that at­tempts at reducing tobacco usage through health policies that affect taxes and advertising are more effective than programs designed around individ­ual behavior change, since persistent tobacco use is not an informed choice but an addictive behavior.

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Baum, H. M., Lund, A. K., & Wells, J. K. (1989). The mortality

consequences of raising the speed limit to 65 MPH on rural interstates. Americanjournal of Publtc Health, 79, 1392-1395.

Berliner, H. S. (1988). Patient dumping- No one wins and we all lose. American journal of Public Health, 78, 1279-1280.

Bernier, R. H. (1994). Toward a more population-based ap­proach to immunization: Fostering private- and public­sector collaboration. AmericanJournal of Public Health, 84,1567-1568.

Hayry, H., Hayry, M., & Karjalainen, S. (1989). Paternalism and Finnish anti-smoking policy. Social Science and Medicine, 28, 293-297.

Kalimo, E. (1971). Medical care research in the planning of social security in Finland. Medical Care, 9, 304-310.

Kellermann, A. 1. (1994). Annotation: Firearm-related vio­lence-What we don't know is killing us. American jour­nal of Public Health, 84, 541-542.

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Kinston, W. (1983). Pluralism in the organisation of health services resean:h. Social Science and Medicine, 17, 299-313.

Krieger,). w., Connell, EA., & LoGerfo,). P. (1992). Medicaid prenatal care: A comparison ofuse and outcomes in fee-for­service and managed care. American journal of Public Health,82,185-19O.

Levine, H. G. (1992). Temperance cultures: Alcohol as a prob­lem in Nordic and English-speaking cultures. In M. Lader, G. Edwards, & c. Drummond (Eds.), The nature of alcohol and drug-related problems. New York: Oxford University Press. [Cited in Peele, 1993]

Levy, S. R. (1986). Work site health promotion. Family and Community Health, 9(3),51-62.

Mariner, W. K. (1994). Patients' rights after health care re­form: Who decides what is medically necessary. American journal of Public Health, 84,1515-1520.

McBeath, W. H. (1991). Health for all: A public health vision. Americanjournal of Public Health, 81, 1560-1565.

Nestle, M. (1994). Editorial: The politics of dietary guidance­A new opportunity. American journal of Public Health, 84, 713-715.

Peele, S. (1993). The conflict between public health goals and the temperance mentality. American journal of Public Health, 83, 805-810.

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Potterat,}.}., Spencer, N. E., Woodhouse, D. E., & Muth,}. B. (1989). Partner notification in the control of human immu­nodeficiency virus infection. American journal of Public Health, 79, 874-876.

Robertson, 1. S., & Zador, P. 1. (1978). Driver education and fatal crash involvement of teenaged drivers. American journal of Public Health, 68, 959-965.

Rodgers, B. 1. (1989). Exploring health policy as a concept. Western journal of Nursing Research, 11, 694-702.

Scheper-Hughes, N. (1994). An essay: AIDS and the social body. Social Science and Medicine, 39, 991-1003.

Somers, A. R. (1986). The changing demand for health ser­vices: A historical perspective and some thoughts for the future. Inquiry, 23(Winter), 395-402.

Urban, N., Anderson, G. 1., & Peacock, S. (1994). Mammogra­phy screening: How important is cost as a barrier to use? American journal of Public Health, 84, 50-55.

Wilder, D. 1. (1978). Persuasion and coercion for health: Ethical issues in government efforts to change life-styles. Health and Society/Millbank Memorial Fund Quarterly, 56, 303-338.